=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972647667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAGWYN LOUISE DURDEN M.S., ATC, LAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 SAN JACINTO BLVD UNIVERISTY OF TEXAS
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78712-1047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-471-7058
-----------------------------------------------------
Fax | 512-232-5054
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4200 LINDO LOOP
-----------------------------------------------------
City | ROUND ROCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78681-2281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-238-7361
-----------------------------------------------------
Fax | 512-232-5054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT1443
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------